Texas Children s Health Plan

Transcription

1 Texas Children s Health Plan The best decision a family can make. CHIP Member Handbook For Harris and Jefferson Service Delivery Areas. November 2014 MS Call us toll-free

2 Quick Guide Who To Call If you need: Texas Children s Health Plan Please call: Member Services, toll-free at or TDD (Texas Relay) or to find out how to get covered services for you or your child. Member Services is ready 8 a.m. to 5 p.m. Monday through Friday. After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Member Service Advocate will return your call the next business day. In case of an emergency, go to your nearest in-network emergency room or call You can speak to a Member Services Advocate in English or Spanish. Interpreters who speak 140 different languages are also available by phone. You can also write us at: Texas Children s Health Plan Attn: Member Services PO Box , NB 8360 Houston, TX A doctor s care Behavioral (mental) health or substance abuse treatmen Your child s primary care provider. His or her phone number is on your child s ID card. Your child s primary care provider is ready 24 hours per day, 7 days a week. Behavioral Health/Substance Abuse Hotline, toll-free at to find out how to get services. Ready 24 hours a day, 7 days a week. No primary care provider referral is needed. The hotline is staffed with individuals who speak English and Spanish. Interpreters who speak 140 different languages are also ready by phone. If you have an emergency need treatment immediately, call or go to the nearest emergency room. Nurse Help Line Toll-free at or TDD (Texas Relay) or Registered nurses are ready 24 hours per day, 7 days a week. Urgent care Emergency care Hospital care Prescriptions Your child s primary care provider or the Nurse Help Line at or TDD (Texas Relay) or Go to an in-network hospital emergency room. If the situation is life threatening call or go to the nearest emergency room. Your child s primary care provider, who will arrange the care your child needs. Member Services toll-free at for the names of participating pharmacies or for help with getting a prescription filled. Re-enrollment information CHIP toll-free at Questions about enrollment fees CHIP toll-free at Update your address and telephone number Member Services, toll-free at or TDD (Texas Relay) or Vision care Call Block Vision toll-free at Dental care Your child s CHIP dental plan. Your child will have one of the following dental plans. DentaQuest MCNA Dental If you don t know who your child s CHIP dental plan is, call the CHIP toll-free at

3 Table of Contents How the Plan Works Your/your child s primary care provider...3 Changing your/your child s primary care physician...4 Your/your child s primary care provider also can ask for changes...5 If you/your child s primary care provider leaves Texas Children s Health Plan...5 Your/your child s Texas Children s Health Plan member ID card... 6 When you/your child needs to see a doctor Care after hours Routine care... 7 Urgent care Emergency medical or behavioral health care...8 Post-stabilization care....9 Care when you are away from home....9 Referrals and specialty care Services that do not need a referral from your/your child s primary care provider OB/GYN care Inpatient hospital services Home health services Benefits and Services Covered benefits and services Medically necessary health care Copayments for certain medical services CHIP cost-sharing caps...13 Behavioral health and drug abuse services What if I/my daughter is pregnant? Who do I need to call? Prescription drugs Vision care...15 Dental care...15 Extra benefits for Texas Children s Health Plan members Children with special health-care needs Health education classes Health risk assessments Preventive health guidelines Member Services Interpreter and translation services Help for the visually impaired Phone device for the deaf services for members with hearing or speech impairments Member materials available in English and Spanish What to do if you move...18 Requesting reimbursement for claims paid for emergency care...18 What to do if you get a bill from a provider Changes in Texas Children s Health Plan Rights and Responsibilities Confidentiality of personal health information...19 Changing health plans Your health plan can also ask for changes Second opinions...19 Renew your/your child s CHIP benefits on time Information you can ask for and get from Texas Children s Health Plan each year Provider incentive plans When you are not satisfied or you have a complaint When your doctor s request for covered services is not approved or limited What if the services my child needs are for an emergency or if my child is in the hospital? When you can request an independent review Member rights Member responsibilities Report CHIP waste, abuse, or fraud New medical procedures review CHIP Perinatal...27

4 Welcome to Texas Children s Health Plan We are happy that you picked Texas Children s Health Plan for your family. Texas Children s Health Plan was founded in 1996 by Texas Children s Hospital. Texas Children s Health Plan is the nation s first health maintenance organization (HMO) created just for children. Texas Children s Health Plan has more than 330,000 members. The staff and group of over 700 primary care physicians, 1,400 specialists and 40 hospitals provide excellent service and patient care to our members. As a member, you will have use of special services such as our Keep Fit Program for our members who need help losing weight. We also offer special events such as FREE soccer clinics and movie day for our members. This is your member handbook for CHIP members and CHIP Perinate Newborn members. It will help you know how your/your child s health plan works. It tells you what to expect and how to get the most out of your/your child s coverage under CHIP. It includes information on: How to get health care when you/your child is sick. How to change your/your child s doctor. What to do if you/your child gets sick while out of town or when your doctor s office is closed. What copayments are needed for certain medical services. How to call the health plan when you have questions or need help. What benefits and services are covered. Extra services offered by Texas Children s Health Plan. Your rights and responsibilities as a plan member. Please take a few minutes and read this handbook carefully. If you have trouble understanding, reading, or seeing the information in this handbook, call Member Services for help. Our Member Advocates can give special services to meet your needs. For example, if needed, this handbook can be given to you in audio, larger print, Braille, and in other languages. Call Member Services at or toll-free at , TDD (Texas Relay) or With the help of on-line interpreters, Member Advocates can speak to you in 140 languages. It is important to us to keep you/your child healthy. That is why we want you/your child to get regular well checkups and keep their immunizations up to date. It is also important to start and keep a relationship with a primary care provider. A primary care provider can be a doctor or clinic that gives you most of your health care. You and your child s doctor will work together to keep you/your child healthy and take care of you/him or her when they are not well. Here are 3 things you need to do to get the most from your health coverage: 1. Always carry your/your child s Texas Children s Health Plan member ID card with you. Your Texas Children s Health Plan member ID card is the key to getting care. Show it every time you visit a doctor, hospital, or get a prescription filled. Do not let anyone else use your card. 2. Stay focused on prevention. As a new member you/your child should have their first checkup within 90 days after joining Texas Children s Health Plan. During the first visit your/your child s doctor will learn what you/he or she needs to help keep them healthy. 3. Call your primary care provider first for non-emergency care. Except in the case of an emergency, always call your primary care provider first. That way, he or she can help you get the care you need. Keep this handbook and the other information enclosed in your packet for future use. The Evidence of Coverage and Schedule of Benefits for CHIP are in the pocket of this handbook cover. These documents give you details about: Eligibility for enrollment. When coverage ends. Benefit limitations and exclusions. Needed copayments. References to you, my, or I apply if you are a CHIP member. References to my child or my daughter apply if your child is a CHIP member or a CHIP Perinate Newborn member. 2 We are glad you picked Texas Children s Health Plan. It is our pleasure to serve you. Our Member Advocates are ready to help you. If you have any questions about benefits, doctors in our network, our extra services, or have a concern, call Member Services toll-free at , TDD (Texas Relay) or

5 How the Plan Works Call toll-free Texas Children s Health Plan was founded on the belief that you and your child s primary care provider are the 2 best able to make decisions about your/your child s health care. Texas Children s Health Plan gives you use of a group of doctors, hospitals, and other health service providers that have had special training to care for children, adolescents, and teens. Texas Children s Health Plan is a managed care plan. This means that you will need to use the doctors and other providers who are in Texas Children s Health Plan s network. Your/your child s doctor, referred to as the primary care provider, will give you/your child all of his or her routine care. Most of the time you will need to go to your primary care provider first. If you choose to go to another doctor, you might have to pay for the services. Remember always take your member ID card with you each time you get health services. Primary care provider What is a primary care provider? Your/your child s primary care provider is considered his or her medical home. Your/your child s primary care provider should have all of your/your child s medical records and know everything about your/your child s past and present health-care needs. If a specialist or tests are needed, the primary care provider will arrange the care. A good relationship with a primary care provider helps you keep you/your child healthy and well. A good way to build a relationship with your/your child s primary care provider is to call and make a well checkup visit. You can meet the doctor and the doctor can meet and get to know you/your child. Can a clinic be my/my child s primary care provider? (Rural Health Clinic/Federally Qualified Health Center) Picking your/your child s primary care provider is an important health decision. Primary care providers can be: Family doctors. Pediatricians (for children and adolescents). General practice doctors. Internal medicine doctors. Advanced nurse practitioners (ANPs). You can also pick a community-based clinic, rural health clinic, or a Federally Qualified Health Clinic (FQHC) as your/your child s primary care provider. You can pick any primary care provider in the Texas Children s Health Plan network. Each child in your family who is a member can pick the same or a different primary care provider. You should pick a doctor with an office location and office hours that are convenient for you. The names, addresses, and phone numbers of primary care providers can be found in the Texas Children s Health Plan Provider Directory. For a current directory, please call Member Services toll-free at If you like the doctor that you/your child sees now, you can keep going to see them if they are listed in the directory. If you have trouble picking a primary care provider, call us. We will be glad to help. It is important that you get to know your/your child s primary care provider right away. It also is important to tell the primary care provider as much as you can about your/your child s health. Your/your child s primary care provider will get to know you/your child, give you/him or her regular checkups, and treat you/him or her when they are sick. It is important that you follow your/your child s primary care provider s advice and take part in decisions about your/your child s health care. It is not wise to wait until you/your child is sick before having your first visit with the primary care provider. Schedule your/your child s first well checkup right away. Member Services can help you. We can also help you get transportation to your doctor s office. Call us toll-free at How the Plan Works

6 4How the Plan Works What do I need to bring to my/my child s doctor s visit? When you/your child needs medical care, simply call the primary care provider s office ahead of time to make an appointment for a visit. Your/your child s primary care provider s name is on the front of your/your child s member ID card. When you call: Have your/your child s member ID card with you. Be ready to describe your/your child s health problem or the reason for the visit. If you/your child needs medical care the same day, call the primary care provider as early in the day as possible. Write down the day and time assigned for your/your child s visit. When you go for your visit carry: Your/your child s member ID card. A list of the questions to ask the primary care provider. Also, make a list of any health problems you/your child is having. Any prescription drugs you/your child is taking. Paper to write notes on the information you get from the doctor. If it is your first visit to this doctor also carry the name and address of your/your child s previous doctor and your/your child s shot records. You might be asked to sign a form agreeing to have your/your child s medical records be sent to your/his or her new primary care provider. Be on time for your doctor visits. Call your doctor s office as soon as possible if you are not able to keep your visit or will arrive late. They will help you change the visit to a different day or time. Calling to cancel a visit is sometimes hard to remember, but it is important to do so that others who need visits can get them. There are times when Texas Children s Health Plan will allow a specialist to be your primary care provider. Call Member Services toll-free at to learn more. Your/your child s primary care provider, or another doctor working with him or her, is available 24 hours a day, 7 days a week. Changing your/your child s primary care physician How can I change my/my child s primary care provider? Your relationship with your/your child s doctor is very important. If you decide the primary care provider you chose does not meet your/ your child s needs or if you are told that he or she is no longer a part of Texas Children s Health Plan, you can pick another doctor. You might also want to change your/your child s primary care provider if: You are not happy with the care he or she gives. You need a different kind of doctor. Your primary care provider s office is too far away from you because you have moved. The names, addresses, and phone numbers of the primary care providers in Texas Children s Health Plan can be found in the Texas Children s Health Plan CHIP Provider Directory. For a current directory, or for help picking a new primary care provider, call Member Services at or toll-free at We will be glad to help. You do not have to change health plan to change your primary care provider. Do not change to a new primary care provider without telling us. If you go to a new primary care provider without telling us you might have to pay for the services.

7 Call toll-free How many times can I change my/my child s primary care provider? There is no limit on how many times you can change your or your child s primary care provider. You can change primary care providers by calling us toll-free at or writing to: Texas Children s Health Plan Member Services Department PO Box , NB 8360 Houston, TX When will my /my child s primary care provider change become effective? When you change your/your child s primary care provider the change will take effect the next day. A new member ID card will be mailed to you. The ID card will have your new primary care provider s name and phone number. Be sure to have your/your child s medical records sent to your new doctor. To give you/your child the best care, the primary care provider needs to know your/your child s medical history. What if I want to know more about my/my child s doctor? You can learn more about your doctor such as where he went to school, his specialty, or board certification status on our website at and click the Find a doctor link. Are there any reasons why a request to change a primary care provider may be denied? Sometimes you might not be able to have the primary care provider you picked. This happens when the primary care provider you picked: Cannot see more patients. Does not treat patients your/your child s age. Is no longer a part of Texas Children s Health Plan. What if I choose to go to another doctor who is not my/my child s primary care provider? Always call Member Services to change your/your child s primary care provider before setting up a visit with another doctor. If you choose to go to another doctor who is not your/your child s primary care provider, the doctor might refuse to see you/your child or you might have to pay. Your/your child s primary care provider also can ask for changes Can a primary care provider move me or my child to another primary care provider for non-compliance? Your/your child s primary care provider can ask that you pick another primary care provider if: You miss visits without calling to say you will not be there. You often are late for your visits. You do not follow your primary care provider s advice. You are rude, abusive, or do not cooperate or get along with the primary care provider s office staff. If your/your child s primary care provider asks you to change to a new primary care provider we will send you a letter. The letter will tell you that you need to pick a new primary care provider. If you do not pick a new primary care provider, one will be picked for you. If your/your child s primary care provider leaves Texas Children s Health Plan What if my/my child s primary care provider leaves? If your primary care provider decides to end his or her participation with Texas Children s Health Plan, we will tell you within 15 days of finding out about the doctor s decision. You can pick another primary care provider. Call Member Services toll-free at A Member Advocate will help you make the change. If you/your child is getting medically necessary treatments, you might be able to stay with that doctor if he or she is willing to see you/your child until the treatment is completed. When we find you a new primary care provider on our list who can give you/your child the same type of care, we will change your primary care provider. 5How the Plan Works

8 6How the Plan Works Your/your child s Texas Children s Health Plan member ID card Each of your children will get their own personal member ID card. Carry this card with you at all times. It has important information needed to get medical care. Show it to all health-care providers before you get medical services. It tells providers you/your child is covered by Texas Children s Health Plan. If you do not show your ID card, the doctor might refuse to see you/your child or you might be billed for the services received. You will not get a new member ID card every month. You will get a new member ID card only if: You lose your current member ID card and ask for a new one. You change your/your child s primary care provider. Call Member Services if you/your child needs to see his or her primary care provider before you get your new ID card. We will call and tell your doctor you are a member of Texas Children s Health Plan. How to read your/your child s ID card A copy of the member ID card is shown below. The front shows important information about you/your child. It also has your/your child s member ID number, and the name and phone number of the primary care provider. The bottom-front section of the member ID card has important phone numbers for you to call if you need help using health services. The front of the card shows: Your/your child s name and ID number. Your/your child s date of birth. Your/your child s primary care provider s name, phone number, and start date. The ID card also lists the copayments for covered health services and pharmacy. Copayments are the amounts you need to pay. There are no copayments for CHIP Perinate Newborn members. As soon as you get the member ID card, check to make sure your/your child s information is correct. Call Member Services if you find an error. We will correct the information and send you a new card. Do not let other people use your/your child s member ID card. If the card is lost or stolen, call Member Services. A Member Advocate will send you a new card. How to use your card Remember: Always carry your/your child s member ID card with you. Show the ID card every time you go to a doctor s office. Do not let other people use the card. Call Member Services if you do not have a member ID card for you/your child. Call Member Services if your/your child s member ID card is lost or stolen. How to replace if lost Do not let other people use your/your child s ID card. If the card is lost or stolen, call Member Services at or toll-free at A Member Advocate will send a new card to you.

9 Call toll-free When you/your child needs to see a doctor When your child needs to see a doctor, call your/your child s primary care provider. The phone number is printed on your member ID card. If you set up a visit with your/your child s doctor but find you can t keep it, call to cancel and set up a new date and time. Care after hours How do I get medical care after my primary care provider s office is closed? There can be times when you need to speak to your/your child s primary care provider, but his or her office is closed. For example, you might want medical advice about how to care for you or a sick child. Your/your child s primary care provider or another doctor working with him or her is ready to help 24 hours a day, 7 days a week. Call the primary care provider s office using the phone number on your/your child s ID card. The doctor s answering service will take a message and a doctor or nurse will call you back. Call again if you do not hear from a doctor or nurse within 30 minutes. Some primary care providers phones are answered by an answering machine after hours. The recording will give you another phone number to reach the doctor. Do not wait until evening to call if you can take care of a medical problem during the day. Most illnesses tend to get worse as the day goes on. You also can call the Texas Children s Health Plan Nurse Help Line and talk to a nurse. The toll-free phone number for Texas Children s Health Plan Nurse Help Line is Nurses are ready to help you decide what to do 24 hours a day, 7 days a week. If you have a life-threatening emergency, call right away or go to the nearest emergency room. Routine care What is routine medical care? How soon can I expect to be seen / How soon can I expect my child to be seen? Your/your child s primary care provider will give him or her regular checkups and treat him when he is sick. This is known as routine care. During routine visits your/your child s doctor will give you prescriptions and send you/your child to specialist if he or she needs one. Most routine visits, including well checkups, are scheduled within 2 to 14 days of you asking. When you/your child needs routine care, call your/his or her primary care provider at the phone number on the front of your/your child s ID card. Someone in the doctor s office or clinic will make an appointment for you. It is very important that you keep your visits. If you cannot keep your visit, call the doctor s office to let them know. If more than one of your children need to see the doctor you need a visit scheduled for each child. It is important that you do what your/your child s primary care provider says and that you take part in decisions made about your/your child s health care. If you cannot make a decision about your/your child s health care you can pick someone else to make them for you. Urgent care What is urgent medical care? What should I do if my child or I need urgent medical care / How soon can I expect to be seen? Another type of care is urgent care. There are some injuries and illnesses that are probably not emergencies but can turn into emergencies if they are not treated within 24 hours. Some examples are: Minor burns or cuts. Earaches. Sore throat. Muscle sprains/strains. You should first call your/your child s primary care provider at the phone number shown on the front of the ID card. For urgent care, you should call the primary care provider, even on nights and weekends. Your primary care provider will tell you what to do. In some cases, your primary care provider may tell you to go to an urgent care clinic. If your primary care provider tells you to go to an urgent care clinic, you don t need to call the clinic before going. You need to go to a clinic that takes Texas Children s Health Plan. For help call Member Services at You can also call our 24-hour Nurse Helpline at for help getting thecare you need. You should be able to be sen within 24 hours for an urgent care appointment. 7How the Plan Works

10 8How the Plan Works Emergency medical or behavioral health care What is an emergency, an emergency medical condition, and an emergency behavioral health condition? Emergency care is a covered service. Emergency care is provided for Emergency Medical Conditions and Emergency Behavioral Health Conditions. Emergency Medical Condition is a medical condition characterized by sudden acute symptoms, severe enough (including severe pain), that would lead an individual with average knowledge of health and medicine, to expect that the absence of immediate medical care could result in: Placing the member s health in serious jeopardy. Serious impairment to bodily functions. Serious dysfunction of any bodily organ or part. Serious disfigurement; or In the case of a pregnant CHIP member, serious jeopardy to the health of the CHIP member or her unborn child. Emergency Behavioral Health Condition means any condition, without regard to the nature or cause of the condition, which in the opinion of an individual, possessing average knowledge of health and medicine: Requires immediate intervention or medical attention without which the member would present an immediate danger to himself/herself or others; or Renders the member incapable of controlling, knowing, or understanding the consequences of his/her actions. What is emergency services and/or emergency care? Emergency services and emergency care mean health care services provided in an in-network or out-of-network hospital emergency department, free-standing emergency medical facility, or other comparable facility by in-network or out-of-network physicians, providers, or facility staff to evaluate and stabilize emergency medical conditions or emergency behavioral health conditions. Emergency services also include any medical screening examination or other evaluation needed by state or federal law that is necessary to decide whether an emergency condition or an emergency behavioral health condition exists. How soon can I expect to be seen / How soon can I expect my child to be seen? You can expect / your child can expect to be seen as soon as is appropriate for your/his or her medical condition. Go to/take your child to the nearest hospital if you think you/he or she has a life-threatening emergency condition. You can call for help in getting to the hospital emergency room. After you/your child gets care, call your primary care provider within 48 hours or as soon as possible. The primary care provider will give or set up any follow-up care you/your child might need. If you get follow-up care from a doctor other than your primary care provider without your doctor s approval, Texas Children s Health Plan might not pay for the care.

11 Call toll-free If you are sure your/your child s situation is not life threatening, but are not sure if you/he or she needs emergency care, call your/your child s primary care provider. The primary care provider will help you decide if you should go to the emergency room. If you feel that taking the time to call the primary care provider will endanger your/your child s health, get care immediately at the nearest emergency room. You might have to pay the bill if you go/take your child to the emergency room for a condition that is not urgent or emergent. Emergencies can be things like: A badly injured arm, leg, hand, foot, tooth, or head. Severe burns. Bad chest pains. Heavy bleeding. Criminal attack (raped, mugged, stabbed, gunshot). A severe allergic reaction or have been bitten by an animal. Choking, passed out, having a seizure, or not breathing. Acting out of control and are a danger to self or others. Poisoned or overdosed on drugs or alcohol. Remember to show your/your child s member ID card to the emergency room staff. Are Emergency Dental Services Covered? Texas Children s Health plan will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting, such as services for: Treatment of a dislocated jaw. Treatment of traumatic damage to teeth and supporting structures. Removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment for craniofacial anomalies. Drugs for any of the above conditions. Texas Children s Health Plan also covers other dental services your child gets in a hospital, urgent care center, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need, like anesthesia. What do I do if I need/my child needs Emergency Dental Care? During normal business hours, call your/your child s main dentist to find out how to get emergency services. If you/your child needs emergency dental services after the main dentist s office has closed, call us toll-free at Post-stabilization care What is post stabilization? Post-stabilization care services are services covered by CHIP that keep your condition stable following emergency medical care. Care when you are away from home What if I get sick when I am out of town or traveling/what if my child gets sick when he or she is out of town or traveling? If you/your child needs medical care when traveling, call us toll-free at and we will help you find a doctor. If you/your child needs emergency services while traveling, go to a nearby hospital, then call us toll-free at What if I/my child is out of the country? Medical services performed out of the country are not covered by CHIP. 9How the Plan Works

12 How the Plan Works What if I/my child is out of the state? If you/your child is sick or injured and not in serious danger when traveling outside the state, call your primary care provider for advice or instruction. You can also call the Texas Children s Health Plan Nurse Help Line and talk to a nurse. The toll-free phone number is Nurses are ready to help you decide what to do 24 hours a day, 7 days a week. If you/your child has a life-threatening emergency when you are outside of the state, go to the nearest hospital emergency room or call If you seek non-urgent follow-up care without prior authorization, Texas Children s Health Plan might not pay for the care. Remember, there is no coverage for routine care given outside the Texas Children s Health Plan service area. Routine care includes checkups, physical exams, follow-up care, tests, or non-urgent surgeries. Referrals and specialty care What if I need/my child needs to see a special doctor (specialist)? What is a referral? Your/your child s primary care provider is the only doctor you need for most health-care services. If you/your child has a special health problem, you/his or her primary care provider might ask you to see another doctor or have special tests done. This is called a referral. Your/your child s primary care provider will refer you to a specialist or other doctor who is in the Texas Children s Health Plan network. Specialists include doctors such as cardiologists (heart), dermatologists (skin), or allergists. Your/your child s primary care provider will make sure that you/your child sees the right specialist for your/his or her condition or problem. Your primary care provider will discuss with the specialist the need for more treatment, special tests, or hospital care. If you visit a specialist without being referred by your/your child s primary care provider, you might have to pay the specialist for the services given or ordered. Except in an emergency situation, always check with your/your child s primary care provider before you go anywhere else for care. Typically, Texas Children s Health Plan will not cover the costs of medical care from doctors outside of the network. However, there might be times when your/your child s doctor believes it is critical for you/your child to get care from a doctor outside of the network. In these cases, your/your child s doctor will work with Texas Children s Health Plan to get approval. Your doctor will submit a request, in writing, to our Medical Director for authorization of medically necessary services that are not available from any other doctor or other provider in the Texas Children s Health Plan network. How soon can I expect to be seen by a specialist / How soon can I expect my child to be seen by a specialist? Expect visits with specialists to happen within 30 days of your request. If you see a specialist without being referred by your primary care provider, the specialist might refuse to see you. Except in an emergency situation, always check with your/your child s primary care provider before you go anywhere else for care. Services that do not need a referral from your/your child s primary care provider What services do not need a referral? There are certain types of health care that you/your child can get without being referred by the primary care provider: Those services include, when given by a Texas Children s Health Plan network provider: Emergency care. Vision care. Mental health or drug abuse treatment. Obstetrical/gynecological (OB/GYN) care, including routine exams, prenatal care, and postpartum care. Chiropractor care. 10

13 Call toll-free OB/GYN care What if I/my daughter needs OB/GYN care? Will she need a referral? Does she have the right to pick an OB/GYN? ATTENTION FEMALE MEMBERS: You have the right to pick an OB/GYN for yourself/your daughter without a referral from your/your daughter s primary care provider. An OB/ GYN can give you: One well-woman checkup each year. Care related to pregnancy. Care for any female medical condition. Referral to special doctor (specialist) within the network. How the Plan Works Texas Children s Health Plan allows you/your daughter to pick an OB/GYN for you/your daughter but this doctor must be in the same network as your/your daughter s primary care provider. How do I pick an OB/GYN? Check our provider directory to find an in-network OB/GYN. You can also call Member Services toll-free at We will be happy to help you pick a doctor. If I do not pick an OB/GYN, do I have direct access or will I need a referral? You can contact any OB/GYN in the Texas Children s Health Plan network directly to get services. How soon can I/my daughter be seen after contacting the OB/GYN for a visit? You should be seen within 14 days of asking for a visit. Can I/ my daughter stay with an OB/GYN if she is not with Texas Children s Health Plan? Texas Children s Health Plan has limited your/your daughter s selection of an OB/GYN to the same network as your/her primary care provider. This means you/your daughter must look for care from a participating OB/GYN. If you go/take your daughter to a nonparticipating OB/GYN, the health services received or ordered will not be covered. Participating OB/GYNs are listed in the Texas Children s Health Plan CHIP Provider Directory. Inpatient hospital services Your/your child s primary care provider or a specialist might decide you/he or she needs care at a hospital. The doctor will plan for care at a hospital that is in the Texas Children s Health Plan s network. Your coverage includes both outpatient and inpatient services. Your/your child s primary care provider or specialist will need to approve or refer you for these services. Home health services Sometimes a sick or injured child needs medical care at home. Home care can also follow an inpatient stay or be provided to prevent an inpatient stay. If you/your child needs home health services, your/your child s primary care provider will talk to Texas Children s Health Plan so that you/your child can get the right care. 11

14 Benefits and Services Benefits and Services Covered benefits and services What are my/my child s CHIP benefits? How do I get these services? How do I get these services for my child? Are there any limits to any covered services? You will find detailed information about covered benefits and services, limitations, and exclusions in the Schedule of Benefits inserted in the pocket of this handbook. Covered CHIP services must meet the CHIP definition of medically necessary. If you have any questions about a covered service, call Member Services at or toll-free at References to you, my, or I apply if you are a CHIP member. References to my child apply if your child is a CHIP member or a CHIP Perinate Newborn member. Medically necessary health care Covered services for CHIP members, CHIP Perinate Newborn members, and CHIP Perinate members must meet the CHIP definition of medically necessary. A CHIP Perinate member is an unborn child. Medically necessary means: 1. Health-care services that are: Reasonable and necessary to prevent illnesses or medical conditions, or give early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life. Provided at appropriate facilities and at the appropriate levels of care for the treatment of a member s health conditions. Consistent with health care practice guidelines and standards that are endorsed by professionally recognized health-care organizations or governmental agencies. Consistent with the diagnoses of the conditions. No more intrusive or restrictive than necessary to give a proper balance of safety, effectiveness, and efficiency. Not experimental or investigative; and Not primarily for the convenience of the member or provider. 2. Behavioral health services that are: Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder. Are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care. Are furnished in the most appropriate and least restrictive setting in which services can be safely provided. Are the most appropriate level or supply of service that can safely be provided. Could not be omitted without adversely affecting the member s mental and/or physical health or the quality of care rendered. Are not experimental or investigative; and Are not primarily for the convenience of the member or provider. Copayments for certain medical services What are copayments? How much are they and when do I have to pay them? Copayments for medical services or prescription drugs are paid at the time you/your child gets services. Some services have no copayments. Your/your child s member ID card lists your/his or her copayments. Be sure to present the member ID card when you seek service for you/ your child. There are no copayments for CHIP Perinate Newborn members. A copayment is when you have to pay a part of your bill each time you get certain health care. The table below lists the CHIP copayment schedule according to family income. Copayments for medical services or prescription drugs are paid to the health-care provider at the time of service. Your/your child s Texas Children s Health Plan ID card lists the copayments that apply to you/your child. Present your/your child s ID card whenever you/your child gets health-care services. No copayments are paid for preventive care, such as vaccinations, well-child, or well-baby checkups. 12

15 Call toll-free CHIP cost-sharing caps The member guide you received from CHIP when you enrolled in CHIP includes a tear-out form to track your CHIP expenses. There is no cost sharing for CHIP Perinate Newborn members. To ensure that you do not exceed your cost-sharing limit, please keep track of your CHIP-related expenses on this form. The enrollment packet welcome letter tells you exactly how much you must spend before you are able to get to mail the form back to CHIP. If you have misplaced your welcome letter, please call CHIP toll-free at and they will tell you your yearly cost-sharing limit. When you reach your yearly cap, please send the form to CHIP and they will tell your health plan. Your health plan will issue a new member ID card. This new card will show that no copayments are due when your child receives services. Your family might also need to pay a once a year enrollment fee. These fees range from $0 to $50 each 12-month enrollment period. There is no enrollment fee for CHIP Perinate Newborn members. Benefits and Services Federal Poverty Level Office visits Emergency room visit Inpatient stay Generic drugs Brand drugs Native Americans $0 $0 $0 $0 $0 $0 At or below 100% 101% to 150% 151% to 185% 186% to 200% Yearly reporting caps $3 $3 $15 $0 $3 5% of family yearly gross income $5 $5 $35 $0 $5 5% of family yearly gross income $20 $75 $75 $10 $35 5% of family yearly gross income $25 $75 $125 $10 $35 5% of family yearly gross income Behavioral health and drug abuse services How do I get help if I/my child if he or she has behavioral (mental) health or drug problems? Do I need a referral for this? You can get mental health or substance abuse services when needed. You do not need a referral from your/your child s PCP. These services include: Counseling services. Detoxification and treatment for drug addiction and alcoholism. Inpatient and outpatient care. You can get behavioral health or substance abuse services by: Calling the Texas Children s Health Plan Behavioral Health/Substance Abuse Hotline toll-free at The hotline takes calls 24 hours a day, 7 days a week. Choosing a behavioral health or substance abuse provider from the Texas Children s Health Plan provider network. If you have an emergency and need mental health treatment immediately, go to the nearest emergency room or call the Texas Children s Health Plan Behavioral Health/Substance Abuse Hotline toll-free at Someone will help you get care right away. What if I am pregnant/what if my daughter is pregnant? Who do I need to call? Call Texas Children s Health Plan Member Services at or toll-free at as soon as you know you/your daughter is pregnant. You/she needs to apply for Medicaid services right away. Your/your daughter s baby will be enrolled in Medicaid from birth to a year if you/she joins Medicaid while you/she is pregnant. If you/your daughter does not join in Medicaid while you/she is pregnant, you/she will have to apply for coverage for your/her newborn after the baby is born. Please note there could be a gap in coverage for your/her baby. 13

16 Benefits and Services What other services/activities/education does the plan offer pregnant women? Texas Children s Health Plan has a maternal child program called Star Babies for pregnant women. The Star Babies program provides support and education throughout the pregnancy and the beginning of the baby s life. A team of nurses and health educators will help your daughter: Pick an OB/GYN. Schedule visits to the doctor for mom and baby. Get prenatal care education. Learn about the Women, Infants, and Children (WIC) program. Attend maternity fairs. Find parenting resources. To learn more about how to get these services, call Member Services at or toll-free at and ask to speak to a Star Babies specialist. Prescription drugs What are my prescription drug benefits? / How do I get my child s medication? CHIP covers most of the medicine your/your child s doctor says you need. Your/your child s doctor will write a prescription so you can take it to the drug store, or may be able to send the prescription for you. Exclusions include: contraceptive medications prescribed only for the purpose to prevent pregnancy and medications for weight loss or gain. You may have to pay a copayment for each prescription filled depending on your income. Copayments do not apply for CHIP Perinate Newborns. What do I bring with me to the drug store? When you go to the drug store, take your prescription and your Texas Children s Health Plan member ID card. How do I find a network drug store? You may have your prescription filled at any drug store that accepts Texas Children s Health Plan CHIP. If you need a list of drug stores that take Texas Children s Health Plan CHIP, call Member Services at or visit our website at org and click on the Pharmacy Directory under the CHIP Members section. What if I go to a drug store not in the network? If you go to a drug store not in the network, you may not get your prescription filled, or may have to pay for it yourself. For a list of participating pharmacies, call Member Services at or visit our website at and click on the Pharmacy Directory under the CHIP Members section. What is a Drug Formulary? The formulary is a list of drugs chosen by doctors and pharmacists on the basis of quality and therapeutic value. It is a guide for doctors to know which drugs are covered. It includes brand name drugs and generics. Who decides what drugs are on the formulary? Formulary drugs are picked by a group of doctors and pharmacists. Only drugs that are safe, effective, and affordable are picked to be on the list. The group also selects drugs based on therapeutic value, side effects, and costs as compared to like medicines. Where can I go to find out what drugs are covered? Your formulary is on the Navitus website at You can search for a certain drug. You can also browse through lists of drugs. Also included is information about which drug needs prior approval and/or have quantity limits. It does not list every covered drug. The coverage or tier for each drug product is noted. But the dollar amount you pay for each drug is not listed. Contact Texas Children s Health Plan for your drug co-pay information. Do some drugs ordered by my/my child s doctor require prior approval? Some drugs ordered by your doctor may require prior approval. Your doctor may request a prescription drug prior approval by faxing a drug prior approval form to Sometimes you may experience a delay in getting your prescription filled. This is because Texas Children s Health Plan may have requested additional information from your doctor. Please remind your doctor when your medication requires a prior approval. If a drug does not appear in the drug list, your doctor may request a review by the Pharmacist by faxing a drug prior approval form to

17 Call toll-free How do I file a complaint or an appeal for medications ordered by my doctor? The doctor will work with Navitus to request an exception to the formulary if needed. You have the right to appeal if you do not get an exception. When you have a concern about a pharmacy benefit, claim, or other service, please call Texas Children s Health Plan at If your issue or concern is not resolved, you have the right to file a written appeal. Who do I call if I have problems getting my/my child s medications? If you have problems getting your medications, call Member Services toll-free at for help. What if I can t get the medication my/my child s doctor ordered approved? If your/your child s doctor cannot be reached to approve a prescription, you may be able to get a 3-day emergency supply of your medication. Call Member Services toll-free at for help with your medications and refills. Benefits and Services What if I lose my/my child s medication(s)? If you lose your/your child s medication(s), call Member Services toll-free at for help. What if I need my/my child s medications delivered to me? If you need your/your child s medication(s) delivered, call Member Services toll-free at for help. What if I need/my child needs an over-the-counter medication? The pharmacy cannot give you an over-the-counter medication as part of your/your child s CHIP benefit. If you need/your child needs an over-the-counter medication, you will have to pay for it. What if I need/my child needs more than 34 days of a prescribed medication? The pharmacy can only give you an amount of a medication that you need/your child needs for the next 34 days. For any other questions, please call Texas Children s Health Plan at What if I need/my child needs birth control pills? The pharmacy cannot give you/your child birth control pills to prevent pregnancy. You/your child can only get birth control pills if they are needed to treat a medical condition. Vision care How do I get eye care services / How do I get eye care services for my child? To get eye checkups or eyewear, call Block Vision toll-free at Customer Service Representatives are ready to help you pick a doctor near you. They will also tell you what to do to get your/your child s eyeglasses. One eye exam is covered every 12 months. You do not need a referral from your/your child s primary care provider to get an eye checkup. Dental care How do I get dental services for my child? Your child s CHIP dental plan provides dental services including services that help precent tooth decay and services that fix dental problems. Call your child s CHIP dental plan to learn more about the dental services they offer. Texas Children s Health Plan covers emergency dental services your child gets in a hospital. This includes services the doctor provides and other services your child might need like anesthesia. Are emergency dental services covered? Texas Children s Health Plan will pay for some emergency dental services provided in a hospital, urgent care center, or ambulatory surgical center setting, such as services for: Treatment of a dislocated jaw. Treatment of traumatic damage to teeth and supporting structures. Removal of cysts. Treatment of oral abscess of tooth or gum origin. Treatment for craniofacial anomalies. Drugs for any of the above conditions. Texas Children s Health Plan also covers other dental services your child gets in a hospital, urgent care center, or ambulatory surgical center setting. This includes services from the doctor and other services your child might need, like anesthesia. What do I do if I/my child need emergency dental care? During normal business hours, call your/your child s main dentist to find out how to get emergency services. If your child needs emergency dental services after the main dentist s office has closed, call us toll-free at

18 Benefits and Services Extra benefits for Texas Children s Health Plan members What extra benefits does a member of Texas Children s Health Plan get? How do I get these benefits / How can I get these benefits for my child? When you join Texas Children s Health Plan you/your child gets extra benefits, called value-added services, that CHIP does not offer. To learn more about these services and how to get them, call Member Services at or toll-free at These value added services include: 24-hour nurse line. You can reach the nurse help line at Extra help with getting a ride. Help with getting a ride, or up to $20 gas card, for doctor visits for members who need a ride. Sports and school physicals. One each year for CHIP members age 18 and under. Help for members with asthma. Pest control for certain high-risk CHIP members with asthma. Extra help for pregnant women. Lamaze childbirth education program classes for pregnant CHIP and CHIP Perinatal members and their partners. Health and wellness services. Personal health coach, Weight Watchers, or other weight loss program, and wellness tools for certain CHIP members ages 10 to 18. Up to $50 above basic benefit for stop-smoking products for certain CHIP members ages 13 to 18 each year. Health coaching, education, and referral to stop-smoking programs for CHIP members. Recreation programs. Soccer clinic and 2 tickets (for member and 1 parent) to a professional soccer game for CHIP members ages 8 to 15. Gift programs. 1 $20 gift card for health-related and baby supply items for attending pregnancy and parenting classes for pregnant CHIP and CHIP Perinatal members. 1 $20 gift certificate for completing and verifying a postpartum doctor visit between 21 and 56 days after delivery. Children with special health-care needs Who do I call if I/my child has special health-care needs and I need someone to help me? If you/your child has special health care needs like developmental delays, diabetes, or asthma, call Member Services toll-free at to get more information on how to get help with special health-care needs. Texas Children s Health Plan has a care management program that offers families help with your/their child s special needs. The services range from simple outreach and information to intense care coordination. They also involve social services and other community resources to help families with transportation and basic living needs. A care manager is a nurse who can help you: Find services in your community. Learn more about your/your child s medical condition. Develop a plan of care just for you/your child. Schedule visits with special doctors. Explain covered benefits and services. Work with your/your child s doctors to get medically necessary care for you/your child. Be sure to tell the care manager about any special providers you have been seeing. It is also important to tell your/your child s primary care provider that you/your child has/have special health-care needs. The best way to tell your/your child s doctor is to schedule a visit to see you/ him or her. Health education classes What health education classes does Texas Children s Health Plan offer? We want you and your children to stay safe and healthy. Texas Children s Health Plan has health education classes and programs for parents and children, which include: Injury prevention programs like Safe Sitter, bicycle safety, and car seat safety. Managing diabetes and asthma. Keeping fit by eating right and staying active. We offer these programs in places that are easy to get to. Call Member Services at or toll-free at for information on when these classes are offered. Health risk assessments Every new member gets a questionnaire called the Health Risk Assessment. Your answers help us decide if you/your child could benefit from care management or other special programs. Help us keep you/your child well. Answer the questions on the form. Send it back to Member Services. The postage is prepaid. If you need additional forms, call Member Services at or toll-free at Preventive health guidelines Texas Children s Health Plan promotes the use of preventive services. Your/your child s benefits include immunizations and well checkups. Please discuss your/your child s preventive-care needs with your/his or her primary care provider. 16

19 Member Services Call toll-free Member Services If you have questions about your coverage or need help, please call Member Services. Call or toll-free at The phone number is on the front bottom of your/your child s member ID card. You will need your member ID number when you call. With the help of on-line interpreters, Member Advocates can speak to you in 140 languages. Member Advocates are ready to help you 24 hours a day, 7 days a week. We also welcome your calls to tell us how we are doing. We appreciate feedback and advice on how we can better serve you. Call Member Services if you: Need to pick a primary care provider. Need to know what services are covered. Have questions about specialists, hospitals, and other providers. Get a bill from a doctor. Have a complaint. Move or change your phone number. Need an interpreter for a medical visit. Need to replace an ID card. Don t understand something you get in the mail. Need to get a ride to the doctor. Have any questions. Have problems getting your prescription filled. Member Services Member Services can also give you materials about: Mental health care. Diabetes care. Dental care. Asthma care. Self care. Preventive care. Interpreter and translation services Can someone interpret for me when I talk with my/my child s doctor? Who do I call for an interpreter? How far in advance do I need to call? How can I get a face-to-face interpreter in the doctor s office? We can get you face-to-face sign and language interpretation for doctor visits. Please let us know if you need these services at least 48 hours before your visit. Call Member Services toll-free at , TDD or We also have a language line. Call us from any doctor s office. We will find someone who speaks your language. Call Member Services tollfree at Help for the visually impaired If you have a visual impairment, Texas Children s Health Plan will give you health plan materials in larger print, Braille, or on audiotapes. Call Member Services to discuss your special needs. Phone device for the deaf services for members with hearing or speech impairments Texas Children s Health Plan uses Texas Relay TDD services for members and their parents or guardians who have hearing or speech impairments. For TDD, call Member materials available in English and Spanish This member handbook and all other materials included in your member packet are provided in English and Spanish. Many of the other health educational materials we give to members through our health education library also are available in Spanish. 17

20 Member Services What to do if you move What do I have to do if I/my child moves? As soon as you have your new address, give it to the local HHSC benefits office and Texas Children s Health Plan Member Services toll-free at Before you get CHIP services in your new area, you must call Texas Children s Health Plan unless you need emergency services. You will continue to get care through Texas Children s Health Plan until HHSC changes your address. Requesting reimbursement for claims paid for emergency care If you/your child gets emergency care from a non-participating hospital or doctor, you might have to pay for the care at the time services are given. To be reimbursed, keep a copy of the paid bill and call Member Services at or toll-free for instructions on how to request reimbursement. What to do if you get a bill from a provider What if I get a bill from my/my child s doctor? Who do I call? What information will they need? Participating doctors bill Texas Children s Health Plan directly for services given to members. If you fail to show your/your child s ID card when health services are given, a participating doctor might bill you. If you get a bill for a covered service, call the doctor right away. Tell them to bill Texas Children s Health Plan. Have your/your child s ID card handy so you can give them: Your/your child s ID number. Texas Children s Health Plan s claims address. The phone number for Member Services. Call Member Services at or toll-free to let us know you have received a bill. Have the bill handy so you can tell us the: Doctor s name. Doctor s phone number. Date services were given. Amount of the claim. Doctor s reference number or the account number. We also will call the doctor to follow up. Changes in Texas Children s Health Plan Sometimes Texas Children s Health Plan might make some changes in the way it works, its covered services, or its network of doctors and hospitals. We will mail you a letter when we make changes in the services. 18